Description At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.? Requirements The Nurse Reviewer performs complex medical record reviews of Medicare Part A/B and DMEPOS claims that require clinical judgment in order to assess the potential for overpayment or fraud. Using established criteria/ and clinical guidelines, the Nurse Reviewer is responsible for making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. Required Qualifications Graduation from an accredited school of nursing with current, unrestricted licensure as a Registered Nurse (RN); active compact multistate RN license acceptable License recognized in the jurisdiction(s) relevant to the assigned work; for federal contract work, license must be issued by a body within the United States 2–4 years of clinical experience, with demonstrated ability to apply clinical judgment to medical necessity, coverage, and appropriateness-of-care determinations under NCDs, LCDs, and CMS coverage policy Detail-oriented, with strong working knowledge of medical terminology and clinical documentation standards Associate's degree (or accredited nursing diploma) in a healthcare-related field with a professional clinical background Experience in medical/claims review, including pre- and post-payment claims reviews and/or utilization review Preferred Qualifications MAC or RAC appeals review experience CPC (or similar) coding certification Prior work as a Medicare medical review nurse for a MAC, RAC, QIO, or SMRC-type contractor Insurance industry experience Key Responsibilities Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy Document clear, defensible rationale for payment or denial recommendations Identify evidence of medical record alteration or documentation patterns suggestive of fraud, waste, or abuse Participate in provider education sessions, explaining review rationale directly to providers/suppliers Support claim(s) re-review when additional documentation is submitted Maintain a 95%+ individual accuracy score and participate in inter-rater reliability/peer-review QA activities Complete required annual trainings and maintain HIPAA/PHI compliance Work Environment/Physical Demands The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This is a remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch. Commence is an equal employment opportunity for employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law. Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or hr@commence.ai. #J-18808-Ljbffr
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